Basic Information
Provider Information | |||||||||
NPI: | 1467547471 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | CHILDENS HEALTH CARE ASSOCIATES OF NEW JERSEY PC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | CHCA NJ EMERGENCY MEDICINE | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 100 E PENN SQ FL 9 | ||||||||
Address2: | CHILDRENS HEALTH CARE ASSOCIATES OF NEW JERSEY PC | ||||||||
City: | PHILADELPHIA | ||||||||
State: | PA | ||||||||
PostalCode: | 191073323 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2674259233 | ||||||||
FaxNumber: | 2674259299 | ||||||||
Practice Location | |||||||||
Address1: | 100 BOWMAN DR | ||||||||
Address2: | CHOP CARE NETWORK AT VIRTUA VOORHEES HOSPITAL | ||||||||
City: | VOORHEES | ||||||||
State: | NJ | ||||||||
PostalCode: | 080439612 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8563253000 | ||||||||
FaxNumber: | 2674259299 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/04/2006 | ||||||||
LastUpdateDate: | 11/12/2013 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | SANTA | ||||||||
AuthorizedOfficialFirstName: | MIXZA | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | ENROLLMENT SPECIALIST | ||||||||
AuthorizedOfficialTelephone: | 2674259233 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2080P0204X |   |   | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Emergency Medicine |
ID Information
ID | Type | State | Issuer | Description | 0006558520006 | 05 | PA |   | MEDICAID | 8241601 | 05 | NJ |   | MEDICAID | 0001025402 | 05 | DE |   | MEDICAID | 0227884 | 05 | NY |   | MEDICAID |